{"id":12762,"date":"2021-01-20T20:14:57","date_gmt":"2021-01-20T14:44:57","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=12762"},"modified":"2025-10-22T13:39:28","modified_gmt":"2025-10-22T13:39:28","slug":"clinical-documentation-great-way-to-improve-coding","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/clinical-documentation-great-way-to-improve-coding\/","title":{"rendered":"Clinical Documentation: Great Way to Improve Coding"},"content":{"rendered":"

Medical documentation and coding are bricks and mortar of the medical billing process<\/a>. In the past 25-30 years, we seen the increased importance of documentation and coding. Compliant clinical documentation and coding are essential to every healthcare setting, no matter the individual responsible for and\/or performing the tasks.<\/p>\n

We need to ensure medical necessity is being met, of course, but not to a fault, whereby we are utilizing diagnoses only to obtain the coverage and medical necessity acceptation. We shouldn\u2019t be making or using the EHR (electronic health record) or other technology to lead physicians to a particular diagnosis on the screen or use technology to game the reimbursement system(s).<\/p>\n

Documentation as Foundation for Accurate Coding<\/h2>\n

A core designated clinical documentation set for coding should be used as the key constant source of clinical documentation by coding<\/a> professionals as they conduct all the medical coding for an organization. The collection of accurate and complete coded data is critical to healthcare delivery, research, public reporting, reimbursement, and policy-making.<\/p>\n

Complete, clear, and accurate health record documentation is the foundation for complete and accurate coding. This documentation (electronic or paper-based) must be clear, accurate, complete, and timely in order to produce quality coded data.<\/p>\n

Policies should include facility-specific documentation requirements, payer regulations and policies, and contractual arrangements for coding consultants and outsourcing services. The outsourcing vendor does not tell you what documents they will use to code your encounters; you, the HIM professional, are in charge of this process and should have your outsourcing partner follow your best practice or coding compliance policy.<\/p>\n

Transition to ICD-10<\/h2>\n

Due to the transition from ICD-9 to ICD-10, some documentation subjects will require providers to capture new information while for others it may involve in updating, modifying, and expanding documentation needs. ICD-10<\/a> contains multiple combination codes and documentation must reflect the association between conditions, let\u2019s understand this with the following examples:<\/p>\n